Tissue Differentiation and Diagnostic Accuracy of 99m Tc-PSMA and 99m Tc-MDP Bone Scans in Prostate Cancer Patients

Tissue Differentiation and Diagnostic Accuracy of 99m Tc-PSMA and 99m Tc-MDP Bone Scans in Prostate Cancer Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tissue Differentiation and Diagnostic Accuracy of 99m Tc-PSMA and 99m Tc-MDP Bone Scans in Prostate Cancer Patients Farshad Banouei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3246740/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Prostate cancer is currently the second most common cancer among men worldwide. Given the prevalence of this disease and the costs incurred by society in its diagnosis and treatment, awareness of diagnostic and therapeutic modalities and factors influencing their outcomes is of particular importance. Methods: This prospective study aimed to investigate the diagnostic accuracy of 99m Tc- PSMA scan and 99m Tc-MDP Bone scan in 40 patients with prostate cancer and bone metastases. The study was conducted between 2020 and 2023, and the results were compared based on the tissue differentiation of cancerous tissues. Results: The data analysis revealed that the diagnostic accuracy of 99m Tc- PSMA scan and 99m Tc-MDP Bone scan for grade groups 1-5 ranged from 95.4% to 100% and 95.4% to 100%, respectively. However, none of the results were statistically significant. Specifically, the 99m Tc- PSMA scan demonstrated diagnostic accuracy percentages of 100%, 98.7%, 96.1%, 96.6%, and 95.4%, respectively, for grade groups 1 to 5. Similarly, the diagnostic accuracy of 99m Tc-MDP Bone scan for grade groups 1 to 5 was 100%, 96.3%, 98.7%, 96.6%, and 95.4%, respectively. Conclusion: The statistical analysis of the data suggests that tissue differentiation of prostate cancer does not impact the diagnostic accuracy of 99m Tc- PSMA scan and 99m Tc-MDP Bone scan. Moreover, the Gleason score of tissue samples did not affect the differentiation of cancerous tissues by the scans. Therefore, the findings suggest that 99m Tc- PSMA scan and 99m Tc-MDP Bone scan can provide accurate diagnostic results for prostate cancer patients with bone metastases, regardless of the tissue differentiation or Gleason score. Prostate cancer 99mTc- PSMA scan 99mTc-MDP Bone scan Tissue differentiation Purpose Prostate cancer is currently the second most common cancer among men worldwide [1]. Although the rate of spread of this cancer varies in different regions of the world, studies show that about 30% of these patients, especially in developing countries, present with bone metastases[2]. Due to the progressive nature of the disease and the lack of financial resources in developing countries, extensive research has been carried out to find early and inexpensive methods for diagnosing this disease worldwide. These include using specific antigen combinations such as Prostate-Specific Antigen (PSA) and Digital Rectal Examination (DRE), or whole body scanning using radiopharmaceuticals such as gallium and technetium to detect metastases in symptomatic patients[3]. However, none of these methods are effective in detecting the spread of the disease alone, and they have not been able to surpass other methods as a single method. Due to the cellular and biological nature of prostate cancer and the receptors that exist on the surface of prostate cancer cells, different types of scans are used to detect these cancers. Although many imaging modalities used in other scans are not applicable to prostate cancer, for example, fluorine-labeled deoxyglucose (18F-FDG PET) scan, which is used in the diagnosis of many cancers due to lack of absorption in the prostate bed, it can only be effective in detecting metastases, particularly bone metastases, which is not common in the clinic[4, 5]. Nowadays, some studies have shown that performing a full-body MRI in patients with prostate cancer and breast cancer to check for the presence of metastases can provide information equivalent to FDG PET CT scan. In situations where these scans are not available, it can be used as a substitute[6]. In some studies, it has been seen that MRI provides better anatomical information than nuclear scans[7], but lower value in comparison with PSMA PET/CT scan. The most recent epidemiological studies conducted on this disease show that prostate cancer is more prevalent in African and American races. Additionally, this disease is more aggressive in these regions[8, 9]. This highlights the importance of using the best diagnostic methods with maximum efficiency, particularly in developing countries, where the prevalence of invasive cancers is high due to the lack of financial resources and diagnostic facilities [10-13] Considering these shortcomings, in this study, we aimed to investigate and compare two scans - 99m Tc-PSMA scan and 99m Tc-MDP Bone scan. We also aimed to evaluate the effect of differentiation of cancer tissue samples in these patients on the diagnostic accuracy of these scans. Methods In this prospective study conducted between 2020 and 2023, we examined and studied 51 patients with prostate cancer whose disease was diagnosed using tests and paraclinical methods. Patients with at least one of the following indications were included in the study after providing full explanations and ensuring the availability of scans: High alkaline phosphatase levels (more than 180 ng/ml in this study) Presence of bone pain Stage T2c and above PSA>20 + Stage T1 Stage T2+ PSA > 10 Gleason score of 8 to 10. Patients who did not consent to the scans, had received radiopharmaceuticals within 10 days before the study, or had a history of sensitivity to radiopharmaceuticals were excluded from the study. Eleven patients willing to participate in the study did not meet the inclusion criteria and were excluded, leaving a total of 40 patients who were included in the study. At first, questionnaires containing demographic information, PSA level, Gleason score of the pathological sample obtained from the prostate biopsy, and results of routine tests were completed. Then, The Alborz Engineering Research Center of Molecular Imaging Probes supplied a lyophilized kit for PSMA. Before each use, a bottle of lyophilized reagent was chosen and dissolved by adding 4 mL 0.9% NaCl solution, followed by approximately 5 mL 3.7–4.44 GBq 99mTcO-4 solution. The mixture was heated in a 100 °C water bath for 10 min and analyzed for radiochemical purity (RCP) using high-performance liquid chromatography (HPLC) on an Agilent 1200 system. The 99m Tc-PSMA was rejected if the RCP was less than 95%. The 99m Tc-MDP was obtained from Guangdong CI Pharmaceutical Co., LTD. Fuzhou Branch and underwent quality control (QC) by the manufacturer. For the 99m Tc-PSMA scan, all patients received an intravenous injection of 0.74 GBq (20 mCi) 99m Tc-PSMA. Whole-body planar imaging SPECT/CT was performed 2 h after injection on a Discovery NM/CT 670Pro (GE, USA) with low energy high-resolution collimators. The imaging protocol included planar imaging with a peak energy of 140 keV (99mTc) and scan velocity of 15 cm/min in a 1025 × 256 matrix, and regional SPECT/CT with a camera matrix size of 128 × 128, zoom 1.0, rotation 360°, and 30s/frame for a total of 60 frames. Low-dose CT (130 keV; 60 mAs) was used for CT. For the 99mTc-MDP scan, a dose of 0.74 GBq (20 mCi) 99m Tc-MDP was injected intravenously, and imaging was performed 3 to 5 h later. The imaging instrument and acquisition protocol were the same as those used for the 99m Tc-PSMA scan. Image processing was performed on workstations (Xeleris, General Electric, Waukesha, WI). All images were anonymized and interpreted by 3 senior nuclear medicine physicians and 3 senior radiologists. On SPECT/CT, areas with higher imaging agent uptake than normal tissue after excluding physiological uptake and traumatic fracture were considered “imaging positive bone lesions”. Areas with abnormal SPECT/CT findings but no imaging agent uptake on the corresponding site of SPECT were considered negative lesions. .To facilitate statistical analysis, the whole body was divided into 11 zones: Zone 1: Skull Zone 2: Clavicle Zone 3: Sternum Zone 4: Thorax including the ribs Zone 5: Scapula Zone 6: Forearm, wrist, and fingers of the upper limb Zone 7: Humerus Zone 8: Vertebral column, sacrum, and pelvis Zone 9: Femur Zone 10: Knee Zone 11: Tibia, fibula, and ankle of the lower limb A total of 440 regions (40 patients × 11 regions = 440 regions) were investigated and analyzed statistically. Statistical analysis was performed using SPSS version 25.0. The sensitivity, specificity, and accuracy of both imaging modalities were calculated and compared using the McNemar test. The diagnostic performance of each imaging modality was assessed using receiver operating characteristic (ROC) curves. A p-value less than 0.05 was considered statistically significant. Results In the analysis of the results of this study, a total of 3 patients had Gleason score 3 + 3 = 6 (GG = 1), 15 patients had Gleason score 3 + 4 = 7 (GG = 2), 7 patients had Gleason score 4 + 3 = 7 (GG = 3), 11 patients had Gleason score 4 + 4 = 8 (GG = 4), 2 patients had Gleason score 4 + 5 = 9, and 2 patients had Gleason score 5 + 5 = 10 (GG = 5). In the GG = 1 group, the diagnostic accuracy was 100% for both scans, and no false positives or false negatives were observed. In the GG = 2 group, the diagnostic accuracy of 99m Tc-PSMA scan was 98.7%, and the diagnostic accuracy of 99m Tc-MDP Bone scan was 96.3%. This difference was not statistically significant (P = 0.12). In the GG = 3 group, the diagnostic accuracy of 99m Tc-PSMA scan was 96.1%, and the diagnostic accuracy of 99m Tc-MDP Bone scan was 98.7%. This difference was not statistically significant (P = 0.19). In the GG = 4 group, the diagnostic accuracy of 99m Tc-PSMA scan was 96.6%, and the diagnostic accuracy of 99m Tc-MDP Bone scan was also 96.6%. The two groups were completely equal. In the GG = 5 group, the diagnostic accuracy of 99m Tc-PSMA scan and 99m Tc-MDP Bone scan was 95.4%, and the two groups were completely equal. Table 1 summarizes the findings. Table 1 Scans Findings in details GG = 1 Scan type The results of the scans The results of the scans separately 99m Tc-PSMA SCAN The number of 3 patients and a total of 33 areas 0 positive areas 0 true positive areas [0%] 0 false positive areas [0%] 33 negative areas 33 true negative areas [100%] 0 false negative areas [0%] 99m Tc-MDP SCAN The number of 3 patients and a total of 33 areas 0 positive areas 0 true positive areas [0%] 0 false negative areas [0%] 33 negative areas 33 true negative areas [100%] 0 false positive areas [0%] GG = 2 99m Tc-PSMA SCAN The number of 15 patients and a total of 165 areas 18 positive areas 18 true positive areas [10.9%] 0 false positive areas [0%] 147 negative areas 145 true negative areas [87.9%] 2 false negative areas [1.2%] 99m Tc-MDP SCAN The number of 15 patients and a total of 165 areas 22 positive areas 18 true positive areas [10.9%] 4 false positive areas [2.4%] 143 negative areas 141 true negative areas [85.5%] 2 false negative areas [1.2%] GG = 3 99m Tc-PSMA SCAN The number of 7 patients and a total of 77 areas 12 positive areas 10 true positive areas [12.9%] 2 false positive areas [2.6%] 65 negative areas 64 true negative areas [83.2%] 1 false negative areas [1.3%] 99m Tc-MDP SCAN The number of 7 patients and a total of 77 areas 9 positive areas 9 true positive areas [11.7%] 0 false positive areas [0%] 68 negative areas 67 true negative areas [87%] 1 false negative areas [1.3%] GG = 4 99m Tc-PSMA SCAN The number of 11 patients and a total of 121 areas 21 positive areas 17 true positive areas [14%] 4 false positive areas [3.3%] 100 negative areas 100 true negative areas [82.7%] 0 false negative areas [0%] 99m Tc-MDP SCAN The number of 11 patients and a total of 121 areas 19 positive areas 16 true positive areas [13.2%] 3 false positive areas [2.4%] 102 negative areas 101 true negative areas [83.4%] 1 false negative areas [1.2%] GG = 5 99m Tc-PSMA SCAN The number of 4 patients and a total of 44 areas 13 positive areas 11 true positive areas [25%] 2 false positive areas [4.4%] 31 negative areas 31 true negative areas [70.6%] 0 false negative areas [0%] 99m Tc-MDP SCAN The number of 4 patients and a total of 44 areas 11 positive areas 10 true positive areas [22.8%] 1 false positive areas [2.2%] 33 negative areas 32 true negative areas [72.8%] Conclusion Given the increasing prevalence of prostate cancer and the exorbitant costs associated with its diagnosis and treatment, it is crucial to use the fastest, most accurate, and cost-effective methods of diagnosis and treatment. In Minamimoto's study, the researchers investigated and compared the power of detecting metastases with various scintigraphy methods. They concluded that some radiological imaging can be as accurate as scans in detecting non-metastases from prostate and breast cancer[ 6 ]. Similarly, Gutzeit and colleagues found that MRI has the same accuracy as nuclear scans but provides more detailed anatomical information [ 7 ]. In a study conducted by Wang and colleagues to investigate the detection power of 99m Tc-PSMA, they showed that combining the scan result with the PSA level and Gleason score of the pathology sample increases the sensitivity of this scan to 92%[ 14 ]. In Nepal's study, which investigated the accuracy of diagnostic modalities and prostate volume, it was found that biopsy accuracy is lower in larger prostate volumes than in lower volumes [ 15 ]. Abdollah and colleagues investigated the relationship between MRI results, biopsy results, and tissue differentiation levels. They found that imaging results can greatly influence the selection of patients for biopsy and the reliability of clinical decisions [ 16 ]. In cancers with a higher Gleason score, the tissue differentiation rate is lower, and cancer cells grow and multiply at a faster rate. Furthermore, the higher expression of the PSMA gene in cancer cells with higher Gleason scores indicates that these cells are more metabolically active and absorb more radiotracer. This naturally increases the diagnostic accuracy of the scan. However, due to the lack of a similar study, we investigated the validity of this hypothesis. Our study was designed to investigate this question. We found that the diagnostic accuracy of both the 99m Tc-PSMA scan and 99m Tc-MDP Bone scan in low-grade groups is around 100%, while in high-grade groups, it is around 96%. This difference was not statistically significant, partially rejecting the hypothesis. Therefore, from the analysis of statistical data, it can be concluded that the reduction of tissue differentiation in prostate cancer does not significantly affect the results of scans. Considering the costs of using PSMA PET CT scan and MRI and the complications of gadolinium injection, such as systemic nephrogenic fibrosis, and the fact that MRI examinations are limited to certain areas of the body, the use of scans such as 99m Tc-PSMA and 99m Tc-MDP Bone scan is more economical. If only one diagnostic modality is considered, the use of PSMA is a more preferable and cost-effective method, considering its role in therapeutic procedures such as lutein therapy. The limitations of prostate cancer detection in developing countries are multifactorial and complex. Therefore, efforts should be made to increase access to screening and diagnostic tools, improve healthcare infrastructure and public education, and increase awareness about prostate cancer among the general population. Addressing these challenges will be critical in reducing the burden of prostate cancer in developing countries. Due to the limitation of this study including the small sample size, Further studies with more samples and using PSMA PET CT scan may be necessary to investigate the hypothesis of the effect of tissue differentiation on the accuracy of scans. In conclusion, given the progressive progress in diagnostic methods for cancers, especially prostate cancer, and the heavy costs of these diagnostic modalities on society, it is vital for physicians to understand the factors that affect the results of these modalities. This knowledge can help avoid unnecessary paraclinical measures for patients. Declarations Statements & Declarations: Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Farshad Banouei. The first draft of the manuscript was written by Farshad Banouei. Data Availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Hamedan University of Medical Sciences in Iran (Date: 2021/05/08/No: IR.UMSHA.REC.1400.284 ) Consent to participate: Written informed consent was obtained from the parents Consent to publish: The authors affirm that human research participants provided informed consent for publication of all data. References Bray, F., et al., Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 2018. 68(6): p. 394–424. Idowu, B.M., Prostate carcinoma presenting with diffuse osteolytic metastases and supraclavicular lymphadenopathy mimicking multiple myeloma . Clinical case reports, 2018. 6(2): p. 253. Manohar, P., T. Rather, and S. Khan, Determination of the optimal cut-off value of serum prostate-specific antigen in the prediction of skeletal metastases on technetium-99m whole-body bone scan by receiver operating characteristic curve analysis . World Journal of Nuclear Medicine, 2020. 19(03): p. 255–259. Jadvar, H., PET of glucose metabolism and cellular proliferation in prostate cancer . Journal of Nuclear Medicine, 2016. 57(Supplement 3): p. 25S-29S. Sonnenschein, C., et al., Negative controls of cell proliferation: human prostate cancer cells and androgens . Cancer Research, 1989. 49(13): p. 3474–3481. Minamimoto, R., et al., Prospective comparison of 99mTc-MDP scintigraphy, combined 18F-NaF and 18F-FDG PET/CT, and whole-body MRI in patients with breast and prostate cancer . Journal of Nuclear Medicine, 2015. 56(12): p. 1862–1868. Gutzeit, A., et al., Comparison of diffusion-weighted whole body MRI and skeletal scintigraphy for the detection of bone metastases in patients with prostate or breast carcinoma . Skeletal radiology, 2010. 39: p. 333–343. Powell, I.J., et al., Evidence supports a faster growth rate and/or earlier transformation to clinically significant prostate cancer in black than in white American men, and influences racial progression and mortality disparity . The Journal of urology, 2010. 183(5): p. 1792–1797. Taitt, H.E., Global trends and prostate cancer: a review of incidence, detection, and mortality as influenced by race, ethnicity, and geographic location . American journal of men's health, 2018. 12(6): p. 1807–1823. Baade, P.D., D.R. Youlden, and L.J. Krnjacki, International epidemiology of prostate cancer: geographical distribution and secular trends . Molecular nutrition & food research, 2009. 53(2): p. 171–184. Teoh, J.Y., et al., Global incidence of prostate cancer in developing and developed countries with changing age structures . PloS one, 2019. 14(10): p. e0221775. Rawla, P., Epidemiology of prostate cancer . World journal of oncology, 2019. 10(2): p. 63. Nelen, V., Epidemiology of prostate cancer . Prostate cancer, 2007: p. 1–8. Wang, T., et al., The efficacy of 99mTc-HYNIC-PSMA SPECT/CT in detecting primary lesions and metastasis in newly diagnosed prostate cancer . Frontiers in Oncology, 2023. 13: p. 1165694. Nepal, S.P., et al., Prostate cancer detection rate and Gleason score in relation to prostate volume as assessed by magnetic resonance imaging cognitive biopsy and standard biopsy . Turkish Journal of Urology, 2020. 46(6): p. 449. Sharqawi, A., et al., Reliability of prostate imaging reporting and data system version 2.1 for excluding clinically significant prostate cancer using a 1.5 tesla scanner . BMC urology, 2023. 23(1): p. 1–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3246740","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":225129603,"identity":"de61d6fa-9f61-4d1b-8277-aa9f24cda17a","order_by":0,"name":"Farshad Banouei","email":"data:image/png;base64,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","orcid":"","institution":"Urology \u0026 Nephrology research center, Hamedan university of Medical Sciences.","correspondingAuthor":true,"prefix":"","firstName":"Farshad","middleName":"","lastName":"Banouei","suffix":""}],"badges":[],"createdAt":"2023-08-08 20:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3246740/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3246740/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43063159,"identity":"b4447a2b-a1c9-49e6-aa27-dbfc6b5b9421","added_by":"auto","created_at":"2023-09-13 12:22:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":309995,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3246740/v1/9c29ccaf-e9a8-40f0-b005-e0bf18defa67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tissue Differentiation and Diagnostic Accuracy of 99m Tc-PSMA and 99m Tc-MDP Bone Scans in Prostate Cancer Patients","fulltext":[{"header":"Purpose","content":"\u003cp\u003eProstate cancer is currently the second most common cancer among men worldwide\u0026nbsp;[1]. Although the rate of spread of this cancer varies in different regions of the world, studies show that about 30% of these patients, especially in developing countries, present with bone metastases[2]. Due to the progressive nature of the disease and the lack of financial resources in developing countries, extensive research has been carried out to find early and inexpensive methods for diagnosing this disease worldwide. These include using specific antigen combinations such as Prostate-Specific Antigen (PSA) and Digital Rectal Examination (DRE), or whole body scanning using radiopharmaceuticals such as gallium and technetium to detect metastases in symptomatic patients[3]. However, none of these methods are effective in detecting the spread of the disease alone, and they have not been able to surpass other methods as a single method.\u003c/p\u003e\n\u003cp\u003eDue to the cellular and biological nature of prostate cancer and the receptors that exist on the surface of prostate cancer cells, different types of scans are used to detect these cancers. Although many imaging modalities used in other scans are not applicable to prostate cancer, for example, fluorine-labeled deoxyglucose (18F-FDG PET) scan, which is used in the diagnosis of many cancers due to lack of absorption in the prostate bed, it can only be effective in detecting metastases, particularly bone metastases, which is not common in the clinic[4, 5]. Nowadays, some studies have shown that performing a full-body MRI in patients with prostate cancer and breast cancer to check for the presence of metastases can provide information equivalent to FDG PET CT scan. In situations where these scans are not available, it can be used as a substitute[6]. In some studies, it has been seen that MRI provides better anatomical information than nuclear scans[7], but lower value in comparison with PSMA PET/CT scan.\u003c/p\u003e\n\u003cp\u003eThe most recent epidemiological studies conducted on this disease show that prostate cancer is more prevalent in African and American races. Additionally, this disease is more aggressive in these regions[8, 9]. This highlights the importance of using the best diagnostic methods with maximum efficiency, particularly in developing countries, where the prevalence of invasive cancers is high due to the lack of financial resources and diagnostic facilities\u0026nbsp;[10-13]\u003c/p\u003e\n\u003cp\u003eConsidering these shortcomings, in this study, we aimed to investigate and compare two scans - \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan. We also aimed to evaluate the effect of differentiation of cancer tissue samples in these patients on the diagnostic accuracy of these scans.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn this prospective study conducted between 2020 and 2023, we examined and studied 51 patients with prostate cancer whose disease was diagnosed using tests and paraclinical methods. Patients with at least one of the following indications were included in the study after providing full explanations and ensuring the availability of scans:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHigh alkaline phosphatase levels (more than 180 ng/ml in this study)\u003c/li\u003e\n \u003cli\u003ePresence of bone pain\u003c/li\u003e\n \u003cli\u003eStage T2c and above\u003c/li\u003e\n \u003cli\u003ePSA\u0026gt;20 + Stage T1\u003c/li\u003e\n \u003cli\u003eStage T2+ PSA \u0026gt; 10\u003c/li\u003e\n \u003cli\u003eGleason score of 8 to 10.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePatients who did not consent to the scans, had received radiopharmaceuticals within 10 days before the study, or had a history of sensitivity to radiopharmaceuticals were excluded from the study. Eleven patients willing to participate in the study did not meet the inclusion criteria and were excluded, leaving a total of 40 patients who were included in the study.\u003c/p\u003e\n\u003cp\u003eAt first, questionnaires containing demographic information, PSA level, Gleason score of the pathological sample obtained from the prostate biopsy, and results of routine tests were completed. Then,\u0026nbsp;The Alborz Engineering Research Center of Molecular Imaging Probes supplied a lyophilized kit for PSMA. Before each use, a bottle of lyophilized reagent was chosen and dissolved by adding 4 mL 0.9% NaCl solution, followed by approximately 5 mL 3.7\u0026ndash;4.44 GBq 99mTcO-4 solution. The mixture was heated in a 100 \u0026deg;C water bath for 10 min and analyzed for radiochemical purity (RCP) using high-performance liquid chromatography (HPLC) on an Agilent 1200 system. The \u003csup\u003e99m\u003c/sup\u003eTc-PSMA was rejected if the RCP was less than 95%. The \u003csup\u003e99m\u003c/sup\u003eTc-MDP was obtained from Guangdong CI Pharmaceutical Co., LTD. Fuzhou Branch and underwent quality control (QC) by the manufacturer.\u003c/p\u003e\n\u003cp\u003eFor the \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan, all patients received an intravenous injection of 0.74 GBq (20 mCi) \u003csup\u003e99m\u003c/sup\u003eTc-PSMA. Whole-body planar imaging SPECT/CT was performed 2 h after injection on a Discovery NM/CT 670Pro (GE, USA) with low energy high-resolution collimators. The imaging protocol included planar imaging with a peak energy of 140 keV (99mTc) and scan velocity of 15 cm/min in a 1025\u0026thinsp;\u0026times;\u0026thinsp;256 matrix, and regional SPECT/CT with a camera matrix size of 128\u0026thinsp;\u0026times;\u0026thinsp;128, zoom 1.0, rotation 360\u0026deg;, and 30s/frame for a total of 60 frames. Low-dose CT (130 keV; 60 mAs) was used for CT.\u003c/p\u003e\n\u003cp\u003eFor the 99mTc-MDP scan, a dose of 0.74 GBq (20 mCi) \u003csup\u003e99m\u003c/sup\u003eTc-MDP was injected intravenously, and imaging was performed 3 to 5 h later. The imaging instrument and acquisition protocol were the same as those used for the \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan.\u003c/p\u003e\n\u003cp\u003eImage processing was performed on workstations (Xeleris, General Electric, Waukesha, WI). All images were anonymized and interpreted by 3 senior nuclear medicine physicians and 3 senior radiologists. On SPECT/CT, areas with higher imaging agent uptake than normal tissue after excluding physiological uptake and traumatic fracture were considered \u0026ldquo;imaging positive bone lesions\u0026rdquo;. Areas with abnormal SPECT/CT findings but no imaging agent uptake on the corresponding site of SPECT were considered negative lesions.\u003c/p\u003e\n\u003cp\u003e.To facilitate statistical analysis, the whole body was divided into 11 zones:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eZone 1: Skull\u003c/li\u003e\n \u003cli\u003eZone 2: Clavicle\u003c/li\u003e\n \u003cli\u003eZone 3: Sternum\u003c/li\u003e\n \u003cli\u003eZone 4: Thorax including the ribs\u003c/li\u003e\n \u003cli\u003eZone 5: Scapula\u003c/li\u003e\n \u003cli\u003eZone 6: Forearm, wrist, and fingers of the upper limb\u003c/li\u003e\n \u003cli\u003eZone 7: Humerus\u003c/li\u003e\n \u003cli\u003eZone 8: Vertebral column, sacrum, and pelvis\u003c/li\u003e\n \u003cli\u003eZone 9: Femur\u003c/li\u003e\n \u003cli\u003eZone 10: Knee\u003c/li\u003e\n \u003cli\u003eZone 11: Tibia, fibula, and ankle of the lower limb\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eA total of 440 regions (40 patients \u0026times; 11 regions = 440 regions) were investigated and analyzed statistically.\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS version 25.0. The sensitivity, specificity, and accuracy of both imaging modalities were calculated and compared using the McNemar test. The diagnostic performance of each imaging modality was assessed using receiver operating characteristic (ROC) curves. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the analysis of the results of this study, a total of 3 patients had Gleason score 3\u0026thinsp;+\u0026thinsp;3\u0026thinsp;=\u0026thinsp;6 (GG\u0026thinsp;=\u0026thinsp;1), 15 patients had Gleason score 3\u0026thinsp;+\u0026thinsp;4\u0026thinsp;=\u0026thinsp;7 (GG\u0026thinsp;=\u0026thinsp;2), 7 patients had Gleason score 4\u0026thinsp;+\u0026thinsp;3\u0026thinsp;=\u0026thinsp;7 (GG\u0026thinsp;=\u0026thinsp;3), 11 patients had Gleason score 4\u0026thinsp;+\u0026thinsp;4\u0026thinsp;=\u0026thinsp;8 (GG\u0026thinsp;=\u0026thinsp;4), 2 patients had Gleason score 4\u0026thinsp;+\u0026thinsp;5\u0026thinsp;=\u0026thinsp;9, and 2 patients had Gleason score 5\u0026thinsp;+\u0026thinsp;5\u0026thinsp;=\u0026thinsp;10 (GG\u0026thinsp;=\u0026thinsp;5).\u003c/p\u003e \u003cp\u003eIn the GG\u0026thinsp;=\u0026thinsp;1 group, the diagnostic accuracy was 100% for both scans, and no false positives or false negatives were observed.\u003c/p\u003e \u003cp\u003eIn the GG\u0026thinsp;=\u0026thinsp;2 group, the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan was 98.7%, and the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan was 96.3%. This difference was not statistically significant (P\u0026thinsp;=\u0026thinsp;0.12).\u003c/p\u003e \u003cp\u003eIn the GG\u0026thinsp;=\u0026thinsp;3 group, the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan was 96.1%, and the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan was 98.7%. This difference was not statistically significant (P\u0026thinsp;=\u0026thinsp;0.19).\u003c/p\u003e \u003cp\u003eIn the GG\u0026thinsp;=\u0026thinsp;4 group, the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan was 96.6%, and the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan was also 96.6%. The two groups were completely equal.\u003c/p\u003e \u003cp\u003eIn the GG\u0026thinsp;=\u0026thinsp;5 group, the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan was 95.4%, and the two groups were completely equal.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the findings.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScans Findings in details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eGG\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScan type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe results of the scans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe results of the scans separately\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-PSMA SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 3 patients and a total of 33 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 true positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e33 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 true negative areas [100%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false negative areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-MDP SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 3 patients and a total of 33 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 true positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false negative areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e33 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 true negative areas [100%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e\u003cb\u003eGG\u0026thinsp;=\u0026thinsp;2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-PSMA SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 15 patients and a total of 165 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e18 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 true positive areas [10.9%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e147 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e145 true negative areas [87.9%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 false negative areas [1.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-MDP SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 15 patients and a total of 165 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e22 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 true positive areas [10.9%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 false positive areas [2.4%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e143 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 true negative areas [85.5%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 false negative areas [1.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e\u003cb\u003eGG\u0026thinsp;=\u0026thinsp;3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-PSMA SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 7 patients and a total of 77 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e12 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 true positive areas [12.9%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 false positive areas [2.6%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e65 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 true negative areas [83.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 false negative areas [1.3%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-MDP SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 7 patients and a total of 77 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 true positive areas [11.7%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false positive areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e68 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67 true negative areas [87%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 false negative areas [1.3%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e\u003cb\u003eGG\u0026thinsp;=\u0026thinsp;4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-PSMA SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 11 patients and a total of 121 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e21 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 true positive areas [14%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 false positive areas [3.3%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e100 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100 true negative areas [82.7%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false negative areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-MDP SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 11 patients and a total of 121 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 true positive areas [13.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 false positive areas [2.4%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e102 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101 true negative areas [83.4%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 false negative areas [1.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e\u003cb\u003eGG\u0026thinsp;=\u0026thinsp;5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-PSMA SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 4 patients and a total of 44 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e13 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 true positive areas [25%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 false positive areas [4.4%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e31 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 true negative areas [70.6%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 false negative areas [0%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003csup\u003e99m\u003c/sup\u003eTc-MDP SCAN\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe number of 4 patients and a total of 44 areas\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e11 positive areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 true positive areas [22.8%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 false positive areas [2.2%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 negative areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 true negative areas [72.8%]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGiven the increasing prevalence of prostate cancer and the exorbitant costs associated with its diagnosis and treatment, it is crucial to use the fastest, most accurate, and cost-effective methods of diagnosis and treatment. In Minamimoto's study, the researchers investigated and compared the power of detecting metastases with various scintigraphy methods. They concluded that some radiological imaging can be as accurate as scans in detecting non-metastases from prostate and breast cancer[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Similarly, Gutzeit and colleagues found that MRI has the same accuracy as nuclear scans but provides more detailed anatomical information [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study conducted by Wang and colleagues to investigate the detection power of \u003csup\u003e99m\u003c/sup\u003eTc-PSMA, they showed that combining the scan result with the PSA level and Gleason score of the pathology sample increases the sensitivity of this scan to 92%[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Nepal's study, which investigated the accuracy of diagnostic modalities and prostate volume, it was found that biopsy accuracy is lower in larger prostate volumes than in lower volumes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAbdollah and colleagues investigated the relationship between MRI results, biopsy results, and tissue differentiation levels. They found that imaging results can greatly influence the selection of patients for biopsy and the reliability of clinical decisions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn cancers with a higher Gleason score, the tissue differentiation rate is lower, and cancer cells grow and multiply at a faster rate. Furthermore, the higher expression of the PSMA gene in cancer cells with higher Gleason scores indicates that these cells are more metabolically active and absorb more radiotracer. This naturally increases the diagnostic accuracy of the scan. However, due to the lack of a similar study, we investigated the validity of this hypothesis.\u003c/p\u003e \u003cp\u003eOur study was designed to investigate this question. We found that the diagnostic accuracy of both the \u003csup\u003e99m\u003c/sup\u003eTc-PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan in low-grade groups is around 100%, while in high-grade groups, it is around 96%. This difference was not statistically significant, partially rejecting the hypothesis. Therefore, from the analysis of statistical data, it can be concluded that the reduction of tissue differentiation in prostate cancer does not significantly affect the results of scans.\u003c/p\u003e \u003cp\u003eConsidering the costs of using PSMA PET CT scan and MRI and the complications of gadolinium injection, such as systemic nephrogenic fibrosis, and the fact that MRI examinations are limited to certain areas of the body, the use of scans such as \u003csup\u003e99m\u003c/sup\u003eTc-PSMA and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan is more economical. If only one diagnostic modality is considered, the use of PSMA is a more preferable and cost-effective method, considering its role in therapeutic procedures such as lutein therapy.\u003c/p\u003e \u003cp\u003eThe limitations of prostate cancer detection in developing countries are multifactorial and complex. Therefore, efforts should be made to increase access to screening and diagnostic tools, improve healthcare infrastructure and public education, and increase awareness about prostate cancer among the general population. Addressing these challenges will be critical in reducing the burden of prostate cancer in developing countries.\u003c/p\u003e \u003cp\u003eDue to the limitation of this study including the small sample size, Further studies with more samples and using PSMA PET CT scan may be necessary to investigate the hypothesis of the effect of tissue differentiation on the accuracy of scans.\u003c/p\u003e \u003cp\u003eIn conclusion, given the progressive progress in diagnostic methods for cancers, especially prostate cancer, and the heavy costs of these diagnostic modalities on society, it is vital for physicians to understand the factors that affect the results of these modalities. This knowledge can help avoid unnecessary paraclinical measures for patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements \u0026amp; Declarations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Farshad Banouei. The first draft of the manuscript was written by Farshad Banouei.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003eData Availability:\u003c/h4\u003e\n\u003cp\u003e\u003cem\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Hamedan University of Medical Sciences in Iran (Date: 2021/05/08/No:\u0026nbsp;\u003c/em\u003e IR.UMSHA.REC.1400.284\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWritten informed consent was obtained from the parents\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors affirm that human research participants provided informed consent for publication of all data.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray, F., et al., \u003cem\u003eGlobal cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.\u003c/em\u003e CA: a cancer journal for clinicians, 2018. 68(6): p.\u0026nbsp;394\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIdowu, B.M., \u003cem\u003eProstate carcinoma presenting with diffuse osteolytic metastases and supraclavicular lymphadenopathy mimicking multiple myeloma\u003c/em\u003e. Clinical case reports, 2018. 6(2): p.\u0026nbsp;253.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManohar, P., T. Rather, and S. Khan, \u003cem\u003eDetermination of the optimal cut-off value of serum prostate-specific antigen in the prediction of skeletal metastases on technetium-99m whole-body bone scan by receiver operating characteristic curve analysis\u003c/em\u003e. World Journal of Nuclear Medicine, 2020. 19(03): p.\u0026nbsp;255\u0026ndash;259.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJadvar, H., \u003cem\u003ePET of glucose metabolism and cellular proliferation in prostate cancer\u003c/em\u003e. Journal of Nuclear Medicine, 2016. 57(Supplement 3): p.\u0026nbsp;25S-29S.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonnenschein, C., et al., \u003cem\u003eNegative controls of cell proliferation: human prostate cancer cells and androgens\u003c/em\u003e. Cancer Research, 1989. 49(13): p.\u0026nbsp;3474\u0026ndash;3481.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinamimoto, R., et al., \u003cem\u003eProspective comparison of 99mTc-MDP scintigraphy, combined 18F-NaF and 18F-FDG PET/CT, and whole-body MRI in patients with breast and prostate cancer\u003c/em\u003e. Journal of Nuclear Medicine, 2015. 56(12): p.\u0026nbsp;1862\u0026ndash;1868.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGutzeit, A., et al., \u003cem\u003eComparison of diffusion-weighted whole body MRI and skeletal scintigraphy for the detection of bone metastases in patients with prostate or breast carcinoma\u003c/em\u003e. Skeletal radiology, 2010. 39: p.\u0026nbsp;333\u0026ndash;343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell, I.J., et al., \u003cem\u003eEvidence supports a faster growth rate and/or earlier transformation to clinically significant prostate cancer in black than in white American men, and influences racial progression and mortality disparity\u003c/em\u003e. The Journal of urology, 2010. 183(5): p.\u0026nbsp;1792\u0026ndash;1797.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaitt, H.E., \u003cem\u003eGlobal trends and prostate cancer: a review of incidence, detection, and mortality as influenced by race, ethnicity, and geographic location\u003c/em\u003e. American journal of men's health, 2018. 12(6): p.\u0026nbsp;1807\u0026ndash;1823.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaade, P.D., D.R. Youlden, and L.J. Krnjacki, \u003cem\u003eInternational epidemiology of prostate cancer: geographical distribution and secular trends\u003c/em\u003e. Molecular nutrition \u0026amp; food research, 2009. 53(2): p.\u0026nbsp;171\u0026ndash;184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeoh, J.Y., et al., \u003cem\u003eGlobal incidence of prostate cancer in developing and developed countries with changing age structures\u003c/em\u003e. PloS one, 2019. 14(10): p.\u0026nbsp;e0221775.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawla, P., \u003cem\u003eEpidemiology of prostate cancer\u003c/em\u003e. World journal of oncology, 2019. 10(2): p.\u0026nbsp;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelen, V., \u003cem\u003eEpidemiology of prostate cancer\u003c/em\u003e. Prostate cancer, 2007: p.\u0026nbsp;1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang, T., et al., \u003cem\u003eThe efficacy of 99mTc-HYNIC-PSMA SPECT/CT in detecting primary lesions and metastasis in newly diagnosed prostate cancer\u003c/em\u003e. Frontiers in Oncology, 2023. 13: p.\u0026nbsp;1165694.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNepal, S.P., et al., \u003cem\u003eProstate cancer detection rate and Gleason score in relation to prostate volume as assessed by magnetic resonance imaging cognitive biopsy and standard biopsy\u003c/em\u003e. Turkish Journal of Urology, 2020. 46(6): p.\u0026nbsp;449.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharqawi, A., et al., \u003cem\u003eReliability of prostate imaging reporting and data system version 2.1 for excluding clinically significant prostate cancer using a 1.5 tesla scanner\u003c/em\u003e. BMC urology, 2023. 23(1): p.\u0026nbsp;1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prostate cancer, 99mTc- PSMA scan, 99mTc-MDP Bone scan, Tissue differentiation","lastPublishedDoi":"10.21203/rs.3.rs-3246740/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3246740/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Prostate cancer is currently the second most common cancer among men worldwide. Given the prevalence of this disease and the costs incurred by society in its diagnosis and treatment, awareness of diagnostic and therapeutic modalities and factors influencing their outcomes is of particular importance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This prospective study aimed to investigate the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc- PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan in 40 patients with prostate cancer and bone metastases. The study was conducted between 2020 and 2023, and the results were compared based on the tissue differentiation of cancerous tissues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The data analysis revealed that the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc- PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan for grade groups 1-5 ranged from 95.4% to 100% and 95.4% to 100%, respectively. However, none of the results were statistically significant. Specifically, the \u003csup\u003e99m\u003c/sup\u003eTc- PSMA scan demonstrated diagnostic accuracy percentages of 100%, 98.7%, 96.1%, 96.6%, and 95.4%, respectively, for grade groups 1 to 5. Similarly, the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan for grade groups 1 to 5 was 100%, 96.3%, 98.7%, 96.6%, and 95.4%, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The statistical analysis of the data suggests that tissue differentiation of prostate cancer does not impact the diagnostic accuracy of \u003csup\u003e99m\u003c/sup\u003eTc- PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan. Moreover, the Gleason score of tissue samples did not affect the differentiation of cancerous tissues by the scans. Therefore, the findings suggest that \u003csup\u003e99m\u003c/sup\u003eTc- PSMA scan and \u003csup\u003e99m\u003c/sup\u003eTc-MDP Bone scan can provide accurate diagnostic results for prostate cancer patients with bone metastases, regardless of the tissue differentiation or Gleason score.\u003c/p\u003e","manuscriptTitle":"Tissue Differentiation and Diagnostic Accuracy of 99m Tc-PSMA and 99m Tc-MDP Bone Scans in Prostate Cancer Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-14 07:57:00","doi":"10.21203/rs.3.rs-3246740/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc9c95bd-59dc-457a-a69b-563728418fbf","owner":[],"postedDate":"August 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-09-13T12:14:26+00:00","versionOfRecord":[],"versionCreatedAt":"2023-08-14 07:57:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3246740","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3246740","identity":"rs-3246740","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}